Screenings in Chesterfield

Name*

First Last

Email*

Please provide an email address so we can send you confirmation of your tickets, your welcome letter and venue information. Please note that some data will be shared with our external evaluators - the University of Nottingham. They will anonymise all data used in any reports. We do not share our data with any other third parties. Our updated Privacy Statement is available here: http://matineederbyshire.rainbownet.uk/about-us/matinee-privacy-statement/

Phone*

Number of tickets for people living with dementia/memory challenges.*

Number of tickets for carers, family members and friends.*

Total number of tickets

Wheelchairs/Mobility Scooters*

Please let us know the number of wheelchairs or mobility scooters you will be bringing so that we can make sure you have a choice of where to sit.

Relationship between carer and person with dementia*

e.g. partner/spouse/ child/ parent/ etc.

Dementia Diagnosis: when was the diagnosis given?*

0-2 years ago
2-5 years ago
5 years ago
None

Living at home?*

Yes
No

How did you hear about Matinée?*

Have you been to a Matinée screening before?*

Yes
No

Transport: do you need transport to get the screening?*

Yes
No

We can put you in touch with a local transport scheme to help you get to screenings. Some financial support may be available to help you access this. Please make sure your contact details are correct.

Age*

60 or under
61-65
66-70
71-75
76-80
81-85
86+

Please tell us the age of the person living with dementia/memory challenges. If your booking is for multiple people, please bring this information with you to the film screening. Thank you.

Screenings in Chesterfield

Miracle on 34th Street [U]

Tuesday 10 December 2019